Transition of Care Coordinator RN/LCSW

About the role

Coordinates transition of care services for TRICARE beneficiaries. The Transition of Care Coordinator provides clinical oversight and coordination for beneficiaries moving between levels of care, supports discharge planning, conducts post-discharge follow up, completes assessments and reassessments as needed, identifies barriers to care, and reviews and processes authorization and referral requests according to policy.

Responsibilities

• Utilizes clinical judgment to identify care coordination needs and facilitate care during any type of transition of care.
• Completes assessments and reassessments for beneficiaries identified as high risk for readmission, evaluating physical, behavioral health, psychosocial, environmental, and support system factors.
• Captures and documents assessments, outreach, interventions, and coordination activities in the Medical Management System (MMS).
• Evaluates discharge instructions, medication changes, durable medical equipment needs, and barriers to adherence or recovery.
• Identifies gaps in care, unmet needs, social determinants of health, and risks for readmission or adverse outcomes.
• Performs post-discharge outreach to confirm follow-up appointments, medication access, understanding of discharge instructions, and continuity of care needs.
• Evaluates and processes referral requests according to policy.
• Communicates with community providers, TRICARE beneficiaries, Military Treatment Facilities (MTF), caregivers, community resources, and interdisciplinary teams to coordinate care.
• Escalates complex clinical, behavioral health, safety, or psychosocial concerns requiring higher level intervention or urgent follow up.
• Prepares and presents cases involving high profile or sensitive issues to the Medical Director for review.
• Serves as a clinical escalation resource and subject matter expert for non-clinical staff, LVNs, and outreach specialists, providing guidance on clinical appropriateness and beneficiary safety.
• Reviews and triages referrals, assessments, and outreach findings to determine appropriate next steps and level of intervention.
• Applies knowledge of HIPAA privacy and security regulations to ensure compliance in daily practice.
• Identifies and reports potential quality or fraudulent cases to Clinical Quality and/or Program Integrity.
• Participates in Quality Improvement Projects, interdisciplinary case discussions, escalation reviews, and audits as indicated in project documents.
• Supports training, mentoring, and ongoing education of staff related to transition of care processes and escalation protocols.
• Maintains compliance with contractual requirements, desk procedures, accreditation standards, and organizational policies.

Requirements

• Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW), with current unrestricted license in appropriate state or territory of the United States
• Current multistate compact license
• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 2+ years' experience in Care Coordination, Case Management, or equivalent
• Proficiency in medical data entry, written skills and Microsoft Office
• Exceptional oral communication skills, strong organizational skills and easily adapts to change

Qualifications

• Bachelor's degree or higher in health-related field
• Case Manager Certification by a certification body (CCMC, ANCC, etc.)
• 3 years' clinical experience
• 2+ years' Managed Care experience

Skills

• Thorough knowledge of internal policies and procedures, utilization management principles, managed care concepts, medical terminology, and medical management system, clinical decision support tools, International Classification of Diseases, and Current Procedural Terminology.
• Ability to meet or exceed production standards in compliance with contract.

Benefits

We offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

Salary range: Around $76,000 - $89,000 per year.

Pay

Salary range: Around $76,000 - $89,000 per year.

Schedule

Availability to work any shift

Works within a standard office environment, or work from home

Extensive phone and computer work with prolonged sitting

Company Overview

Taking Care of Our Nation’s Heroes. It’s Who We Are. It’s What We Do. Do you have a passion for serving those who served? Join the TriWest Healthcare Alliance Team! We’re On a Mission to Serve®! Our job is to make sure that America’s heroes get connected to health care in the community. At TriWest Healthcare Alliance, we’ve proudly been on that important mission since 1996.

TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more.

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.